Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
King, Linda A.
r y CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT 2.a. NAME OF CANDIDATE OR COMMITTEE to'2 5-/4 .Nb/4 ,tip 2.b. IF COMMITTEE, NAME OF CANDIDATE 3. ELECTION DATE 4.a. CAMPAIGN ADDRESS AND PHONE Street or Rural Route City State Zip Code Phone 3.3(1 ,Cs C+-~~~z- ,gi) b. O3 0~. 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) Street or Rural Route City State Zip Code Phone /5. OFFICE ,SooOUGHT (include district number, if applicable) 6. NAME OF POLITICAL TREASURER (may be candidate) WuN; l_.c.'hM/SS1u,A) 1ST. q ToSC'PH Kl.v1 7. CATEGORY OR REPORT (Check one) ❑ Ca ❑ ❑ ❑ ❑ ❑ ❑ FIRST SECOND THIRD FOURTH PRE- PRE- MID-YEAR YEAR-END QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL 8.a. BEGINNING DATE OF REPORTING PERIOD 8.b. ENDING DATE OF REPORTING PERIO -~7- / W-~3-I i/jA 9. (Check one) a. ❑ This campaign is exempt from detailed disclosure because contributions (including in-kind) received total $1,000 or less AND expendi- tures total $1,000 or less for this reporting period. (Complete items 12d., 12e. and 12f.) b. [✓rThis campaign is required to file a detailed financial disclosure because contributions (including in-kind) received total more than $1,000 and/or expenditures total more than $1,000 for this reporting period. 10. I/we do solemnly swear or affirm that the information contained in this campaign financial disclosure report is true and that this report is an accurate accounting of campaign contributions and expenditures required to be reported by the candidate committee by the Campaign Financial Disclosure Act. Additionally, [/we swear or affirm that no campaign contributions have been expended for the personal financial benefit of the candidate or for any other nonpolitical purpose as defined by the federal internal revenue code. J3 / ~,-:I3 -4 signature of candidate date si a ur of political trey u date 11. WITNESS SIGNATURE ~An0, Jdate signature of witness date signature of witness 12. SUMMARY a. BALANCE ON HAND LAST REPORT b. TOTAL RECEIPTS THIS PERIOD LE D $ ~~5- c. TOTAL DISBURSEMENTS THIS PERIOD d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) $ / Liu't r r-r W:_r 0 F e. TOTAL LOANS OUTSTANDING.. E'..9 NJt< $ / /'ro f. TOTAL OBLIGATIONS OUTSTANDING $ SS-1109 (Rev. 2106) Page 1 of RDA 1159 y . ITEMIZED STATEMENT OF CONTRIBUTIONS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD t,O b 14 / FROM: TO: Amount 3. TOTAL ITEMIZED CAMPAIGN CONTRIBUTIONS FROM PRECEDING P (enter $0 if first itemized page) 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED CONTRIBUTION (contributions totaling more than $100 from an contributor) First Name Middle Name Contribution Received For: Amount of Contribution Last Name/Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer First Name Middle Name Contribution Received For: Amount of Contribution Last Name/Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Tip Code Date of Contribution Aggregate This Election Occupation Employer First Name iddle Name Contribution Received For: Amount of Contribution as Name/Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) city State Zip Code Date of Contribution Aggregate This Election Occupation Employer First Name Middle Name Contribution Receive For: Amount of Contribution Last Name/Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer 5. TOTAL ITEMIZED CONTRIBUTIONS (Carry forward to item 3. of next page if additional pages of this form are used.) (If this is the last page of contributions, this amount must be shown in item 15b. of summary.) SS-1131 (Rev. 2/06) Page of RDA 1159 ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE 1. NAME f CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD TO: 03-/ & J5,4 1 tj FROM: - Z7-1 Amount 3. TOTAL ITEMIZED CAMPAIGN EXPENDITURES FROM PRECEDING PAGE (enter $0 if first itemized page) 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED EXPENDITURE (expenditures totaling more than $100 to any payee during the period) First Name Middle Name Purpose of Expenditure J~ Amount of Expenditure ,(.l") -b A t,jy ~,j c-~ 1~4r,Tt,4 L Last Name/Business Name Address '~f~ City State Zip Code M A C U/ L( C LL-CS E_D 6g,9N K A C('Vcr& First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address city State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address GAY State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code 5. TOTAL ITEMIZED EXPENDITURES (Carry forward to Item 3. of next page If additional pages of this form are used.) (If this is the last page of expenditures, this amount must be shown in item 19b. of summary.) SS-1129 (Rev. 4/02) Page of RDA 1159 ITEMIZED STATEMENT OF OBLIGATIONS - CANDIDATE 1. NAME OF CANDItTE OR COMMITT 2. REPORT COVERING THE PERIOD t nJ fj rt / ,v FROM: T0: 3. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED Outstanding Balance Debt Incurred Payments Outstanding Balance OBLIGATION (obligations totaling more than $100 owed to any (Beginning of Period) This Period This Period (End of Period) person/vendor at the end of the reporting period) First Name Middle Name Last Name/Business Name Address City State Zip Code Description of Obligation First Name Middle Name Last Name/Business Name Address city State Zip Code Description of Obligation First Name Middle Name Last Name/Business Name Address city State Zip Code Description of Obligation First Name Middle Name Last Name/Business Name Address Clly State Zip Code Description of Obligation First Name Middle Name Last Name/Business Name Address City State Zip Code Description of Obligation 4. TOTALS (Total from Outstanding Balance - (End of Period) column must also be shown in ftem 23b. on summary page.) AML SS-1127 (Rev. 4/02) Page of RDA 1159 CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT 2.a. NAME Z CANDIDATE OR C ITTE/E^ 2.b. IF COMMITTEE, NAME OF CANDIDATE 3. ELECTION DATE 4.a. CAMPAIGN ADDRESS AND PHONE Street or Rural Route City State Zip Code Phone 3 11 tq-ws 0- Fff1PE-z- /eb. MAR- U/ Lie 77k,11 2V03 6h-o t 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) Street or Rural Route City State Zip Code Phone 5. OFFICE SOUGHT (include district number, if applicable) 6. NAME OF POLITICAL TREASURER (may be candidate) evu N7- ~vrvlnlrssroti% l)15 -A ~o5e'PrI ink ❑ ❑ ❑ ❑ ❑ ❑ ❑ 7. CATEGORY OR REPORT (Check one) FIRST SED THIRD FOURTH PRE- PRE- MID-YEAR YEAR-END DARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL 8.a. BEGINNING DATE OF REPORTING PERIOD 8.b. ENDING DATE OF REPORTING PERIOD 9. (Check one) a. ❑ This campaign is exempt from detailed disclosure because contributions (including in-kind) received total $1,000 or less AND expendi- tures total $1,000 or less for this reporting period. (Complete items 12d., 12e. and 12f.) b. This campaign is required to file a detailed financial disclosure because contributions (including in-kind) received total more than $1,000 and/or expenditures total more than $1,000 for this reporting period. 10. IAve do solemnly swear or affirm that the information contained in this campaign financial disclosure report is true and that this report is an accurate accounting of campaign contributions and expenditures required to be reported by the candidate committee by the Campaign Financial Disclosure Act. Additionally, I/we swear or affirm that no campaign contributions have been expended for the personal financial benefit of the candidate or for any other nonpolitical purpose as defined by the federal internal revenue code. s n lure of candidate date sj nature of political treatuT9 date 11. WITN SS SIGNATURE J / J v/ 7 vTA All A,% - F signature of witness date signature of witness date 12. SUMMARY a. BALANCE ON HAND LAST REPORT $ D b. TOTAL RECEIPTS THIS PERIOD a D o. TOTAL DISBURSEMENTS THIS PERIOD d. BALANCE ON HAND (12.a. plus 12.b. minus 12.cJ v $ ~d J~o2• e. TOTAL LOANS OUTSTANDING $ f. TOTAL OBLIGATIONS OUTSTANDING $ SS-1109 (Rev. 2106) Page 1 of RDA 1159 SUMMARY PAGE - CANDIDATE 13. NAME OF CANDIDATE OR COMMITTEE (In Full) 14. REPORT COVERING THE PERIOD t D FROM: 41-f _ 1 TO:- Z b RECEIPTS 15. CONTRIBUTIONS (other than loans and interest) a. Unitemized Contributions ($100 or less from each source this period) $ 0 b. Itemized Contributions (over $100 from each source this period) $ / c. TOTAL CONTRIBUTIONS (other than loans and interest)(add 15.a. and 15.b.) $ V30. 16. LOANS RECEIVED THIS REPORTING PERIOD $ 17. INTEREST RECEIVED THIS REPORTING PERIOD p 18. TOTAL RECEIPTS (add 15.c., 16., and 17.) (must be shown in item 12.b.) $ DISBURSEMENTS 19. EXPENDITURES (other than loan payments) a. Expenditures ($100 or less each payee this period) (must be listed by category - e.g., printing, postage, gasoline) $ Total of Expenditures ($100 or less each payee) $ b. Itemized Expenditures (Over $100 each payee this period) $ ~irz f, 7 p / t, c. TOTAL EXPENDITURES (other than loan repayments)(add 19.a. and 19.b.) $ _ 0~4 er `t d 20. LOAN REPAYMENTS MADE THIS PERIOD $ 21. TOTAL DISBURSEMENTS (add 19.c. and 20.) (must be shown in item 12.c.) $ 22AWKIND CONTRIBUTIONS a. Unitemized in-kind contributions ($100 or less from each source this period) $ b. Itemized in-kind contributions (over $100 from each source this period) $ c. TOTAL IN-KIND CONTRIBUTIONS RECEIVED THIS PERIOD (add 22.a. and 22.b.) $ 23.013LIGATIONS a. Unitemized Obligations Outstanding ($100 or less each) $ b. Itemized Obligations Outstanding (Over $100 each) $ c. TOTAL OBLIGATIONS OUTSTANDING (add 23.a. and 23.b.) (must be shown i item 12.f.) $ SS-1133 (Rev. 4102) Page of ITEMIZED STATEMENT OF LOANS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD / FROM: 4- 3. TO: n)DA 711 6 A) C', q-1-I COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED LOAN (loans totaling more than $100 from any source during the period) Complete the Following for the Source of the Loan First Name Middle Name Outstanding Loan Balance Loans Loan Outstanding Loan Balance .3-0 (Beginning of Period) Received Payments (End of Period) S ~ F' rF ~ FDA Last Name/Organization Name 0 I . OZ , jJ0 Address / Loan Received For: Date of Loan ` JE)2 5 o N r9 t- L L) A n~ Primary Election ❑ General Election / City State Zip Code l[- ❑ Runoff (Local Elections Only) / List All Endorsers or Guarantors for Above Loan (it more space is needed please attach a page) First Name Middle Name First Name Middle Name Last Name/Organization Name Last NamelOrganization Name Address Address City State Zip Code City State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding First Name Middle Name First Name Middle Name Last Name/Organization Name Last Name/Organization Name Address Address city State Zip Code City Slate Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding First Name Middle Name First Name Middle Name Last Name/Organization Name Last Name/Organization Name Address Address City State Tip Code City State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding First Name Middle Name First Name Middle Name Last Name/Organization Name Last Name/Organization Name Address Address City State Zip Code City State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding 4. Totals for d Loans (complete on last page of itemized loans) Outstanding Loan Balance Loans Loan Outstanding Loan Balance (Total loans received should also be shown in item 16. on summary page.) (Beginning of Period Received P ments End of Period (Total ban payments should also be shown in item 20. on summary page.) (Total outstanding loan balance should also be shown in item 12.e. on front page.) AWk SS-1132 (Rev. 4/02) Page of RDA 1159 ITEMIZED STATEMENT OF OBLIG ONS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD FROM: TO: 3. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED utstanding Balance Debt Incurred Payments Outstanding Balance OBLIGATION (obligations totaling more than $100 owed to any (Beginning of Period) This Period This Period (End of Period) person/vendor at the end of the reporting period) First Name Middle Name Last Name/Business Name Address city state Zip Code Description of Obligation First Name Middle Name Last am usiness Name Address city State Zip Code Description of Obligation First Name Middle Name Last Name/Business Name Address city State Zip Code Description of Obligation First Name Middle Name Last NamelBusiness Name Address City State Zip Code Description of Obligation First Name Middle Name Last NamelBusiness Name Address City State Zip Code Description of Obligation 4.TOTALS (Total from Outstanding Balance - (End of Period) column must also be shown in item 23b. on summary page.) AOL SS-1127 (Rev. 4/02) Page of RDA 1159 ITEMIZED STATEMENT OF CONTRIBUTIONS - CANDIDATE 1. NAME OF CANDIDATE OR COMMIFEE 2. REPORT COVERING THE PERIOD 1. t N b K r & FROM: c-1- I TO: Amount 3. TOTAL ITEMIZED CAMPAIGN CONTRIBUTIONS FROM PRECEDING PAGE (enter $0 if first itemized page) r" 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED CONTRIBUTION contributions totaling more than $100 from an contributor First Name nq Middle Name Contribution Received For: Amount of Contribution J Last Name/Organization Name Z Primary Election ❑ General Election eooK ~5-'D . cro Address ❑ Runoff (Local Elections Only) 0 o O (,D fl.) H i tE-~ ~ f L(- ~ D. City State Zip Code Date of Contribution Aggregate This Election f} fZ U 1 L L l fJ /~7J 7 X03 Occupation . C c--r l 2 t-~ 3 W-14 Employer First Name /~1t Middle Name Contribution Received For: Amount of Contribution FK A N k d rr`1 L f (2 e Last Name/Organization Name Primary Election ❑ General Election 150-0-6 rnE71bUr.c) N ❑ Runoff (Local Elections Only) Address ~D~~ ~ouNT/t <'!S City State Zip Code Date of Contribution Aggregate This Election ~+rz~ 0r 371'03 Occupation Employer First Name iddleName Contribution Received For: Amount of Contribution alLL a an a e ,:Primary Election ❑ General Election ~OwNAS apv•cro Address ❑ Runoff (Local Elections Only) Cily State Zip Code Date of Contribution Aggregate This Election M 2 379'03 Occupation r First Name Middle Name Contribution Received For. Amount of Contribution Last Name/Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer 5. TOTAL ITEMIZED CONTRIBUTIONS (Carry forward to item 3. of next page if additional pages of this form are used.) C?~ (If this is the last page of contributions, this amount must be shown in item 15b. of summary.) 9Wk SS-1131(Rev. 2106) Page of RDA 1159 ITEMIZED STATEMENT OF IN-KIND CONTRIBUTIONS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD FROM: TO: moun 3. TOTAL ITEMIZED IN-KIND CONTRIBUTIONS FROM PRECEDING PAGE (enter $0 if first itemized page) 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED IN-KIND CONTRIBUTION (in-kind contributions totaling more than $100 from any contributor during the period) First Name Middle Name In-Kind Contribution Received For. Value of In-Kind Contribution El Primary Election 1:1 General Election Last Name/Organization Name ❑ Runoff (Local Elections Only) Address Dale of In-ICnd Contribution Aggregate this Election City State Zip Code Description of IMGnd Contribution Occupation Employer First Name Middle Name In-Kind Contribution Received For: Value of In-Kind Contribution ❑ Primary Election ❑ General Election Last Name/Organization Name ❑ Runoff (Local Elections Only) Address Date of In4Qnd Contribution Aggregate this Election City State Zip Code Description of In-Kind Contribution Occupation Employer First Name Middle Name In-Kind Contribution Received For. Value of In-Kind Contribution Primary Election ❑ General Election Last Name/Organization Name ❑ Runoff (Local Elections Only) Address Date of In4Qnd Contribution Aggregate this Election City State Zip Code Description of In-land Contribution Employer Occupation First Name Middle Name In-Kind Contribution Received For. Value of In-Kind Contribution ❑ Primary Election ❑ General Election Last Name/Organization Name ❑ Runoff (Local Elections Only) Address Date of In-Kind Contribution Aggregate this Election City State Zip Code Description of In-tend ContnW" Occupation Employer First Name Middle Name In-Kind Contribution Received For: Value of In-Kind Contribution E] Primary Election El General Election Last NamelOrganization Name ❑ Runoff (Local Elections Only) Address Date of In-land Contribution Aggregate this Election City State Zip Code Description of In-land Contribution n Employer 5. TOTAL ITEMIZED IN-KIND CONTRIBUTIONS (Carty forward to Item 3. of next paged additional pages of this form are used.) (If this is the last page of In-kind auitributions, this amount must be shown in item 22b. of summary.) SS-1128 (Rev. 2108) Page of RDA 1159 ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE 1. NAME OF ANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD I A..' A 1 A)C7 FROM: - 14 TO: Z61 Amount 3. TOTAL ITEMIZED CAMPAIGN EXPENDITURES FROM PRECEDING PAGE (enter $0 if first itemized page) 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED EXPENDITURE (expenditures totaling more than $100 to any payee during the period) First Name Middle Name Purpose of Expenditure Amount of Expenditure Last N siness Name o" S HT r M Address a 3, ~ I L F R D CW A /c' / 1 f1 1 N t-1s q, 3 Ul Gty State Zip Code 3 -7 ~J 0.j First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Addres 7:- a 3 l ~S~ ,dc- u a P>4 , ti 5 (G AJ s o-~ City ✓ State Zip Code 3 L-v c rTO Nt © f { q:5-74 First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name `jam oA) s P2..ln; //J -fNC. oLI I i cf} re (005'TEAR~ -7 14 alit 5,1 A} LE TD/J Sj77770/v P4. C cC,7 / of 1 -L c 5 . lO City State Zip Code JILLr: TW X7777 First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name e q m p A 1 6 F-L / k f} f S E.e v/ e C /f1 H I LE?-' Address I 3 o (4430 1 j C L T-DrS i }~'Tl 0 AJ D. ~2 f n~ i f s / city State Zip Code A (L Ij C7 S t 0 I C c Lb~ts~,~~c -rN ~ 5iAGE First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name 3) -T, M c Address ? c) to C-/,z (0 ti E-ic tl Gty, ~n State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name 6 ~'t A D l C) -F A) I T- c A i- S D, crv ~Tlq V1 Address City State Zip Code 5. TOTAL ITEMIZED EXPENDITURES / (Carty forward to item 3. of next r l [ page AaddiGonal pages of this form are used.) (If this is the last page of expenditures, this amount must be shown in item 19b. of summary.) Awlk SS-1129 (Rev. 4/02) Page of RDA 1159 FINANCIAL DISCLOSURE STATEMENT EXEMPTION Pursuant to TCA 5 2-10-101(b) a candidate is exempt from filing financial disclosure statements: "If a candidate is seeking an office for which service is part-time, compensation is less than $1,000 a month, and the candidate does not spend more than $1,000 to get elected to office, the candidate does not have to file Campaign Financial Disclosure Reports." FEB a [ut' CANDIDATE'S INFORMATION: r~ Candidate's Name: A e, Candidate's Position: co u ti-ry Co M M sS i o AJ s S EFT Residential Address: City: ~ Y L L C State: TN Zip: 3 Vo 3 I hereby state that I meet the above qualifications for exemption and am therefore exempt from filing financial disclosure statements. Candidate's Sig ature Date /11 Witne 's Signature Date If my plans change and I realize I will spend more than $1,000 on my campaign, I will immediately make a financial disclosure report. FEB Appointment of Political Treasurer For State and Local Candidates and Single-Candidate Committees INSTRUCTIONS The Appointment of Political Treasurer statement must be used to appoint a political treasurer as required by the Campaign Financial Disclosure Act (T.C.A. § 2-10-105) for state and local candidates and single- candidate political campaign committees. A state candidate may not receive or expend funds for an election until a political treasurer has been appointed for that election. A local candidate pursuant to T.C.A 2-10-101, maybe exempt from completing this form, please check with county election commission for more information. A candidate may appoint himself or herself as political treasurer. A new form must be filed if the treasurer is changed. Candidates for state public office must file their original Appointment of Political Treasurer statement ONLY with the Registry of Election Finance, 404 James Robertson Parkway, Suite 104, Nashville, TN 37243-1360. Candidates for local public office must file their original Appointment of Political Treasurer statement ONLY with their county election commission. 1. Date: 2. Name of Candidate orrCommittee: 3. Candidate e-mail address: a-19_/4 rN_D A 1-\f to KI NCB I- i jbAr4 AvL. CoM 4. Campaign Address and Phone: City State Zip Code Phone / I v b 2 T~j 3780 33 S. Home Address and Phone (if different than item 4 above): City State Zip Code Phone 6. Office Sought (include district number, if applicable) 7. Party Affliation 8. Election Year i5 ~9. Treasurer Name: 10. Treasurer e-mail address: 11. Treasurer Address and Phone: City State Zip Code Phone :5 /f-tyl 12. Candidate and Treasurer Signature (both signatures must be witnessed. Treasurer can not witness candidate's signature): Signature of Candidate Signature of Treas r r _ I'1 r Q (1--rd Signature of Witness Signature of Witnes Registry of Election Finance SS-1120 (rev 1012010)